Type
of Pay Per Click Service:
(Choose One)
Basic
Neighborhood Plan
Pay
Per Visitor
Pay
Per Click Advertising Management
Your
Business Category(s).
Example:
Roofing Contractor
Are
you in any PPC programs now?
No
Yes
Are
you using any third party PPC software
now?
No
Yes
Do
you have any text ads to market your
business?
No
Yes
Approximately
how many visitors would you like?
#
PPC per Day
Week
Month
Your
target languages and countries.
What
is your budget per visitor?
$
What
is your PPC budget per month?
$
How
soon would you like to start receiving PPC
visitors?
>>
Select
Immediately
A few days
1 - 2 Weeks
1 Month
or more
How
long do you expect to use our PPC
management service?
>>
Select
Long
Term ( If I keep getting a good return )
1 Month
6 Months
One Year
Not Sure
You
Website Name
(leave blank if you
don't have one)
www.
Do
you have "Landing Pages" for PPC
Visitors? This
is a page on your website that is designed
for your PPC ad. We can provide this if
needed.
No
Yes
I
do not know.
If
you do not have an account with us, you
must fill this section in.
Company
Name
Account
#
Leave blank if you don't
have one.
Contact
Name (Last, First)
State
Country
United
States
Afghanistan
Albania
Algeria
American
Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua
and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaidjan
Bahamas
Bahrain
Banglades
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bolivia
Bosnia-Herzegovina
Botswana
Bouvet
Island
Brazil
British
Indian O. Terr.
Brunei
Darussalam
Bulgaria
Burkina
Faso
Burundi
Buthan
Cambodia
Cameroon
Canada
Cape Verde
Cayman
Islands
Central
African Rep.
Chad
Chile
China
Christmas
Island
Cocos
(Keeling) Isl.
Colombia
Comoros
Congo
Cook
Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech
Republic
Czechoslovakia
Denmark
Djibouti
Dominica
Dominican
Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial
Guinea
Estonia
Ethiopia
Falkland
Isl.(Malvinas)
Faroe
Islands
Fiji
Finland
France
France
(European Ter.)
French
Southern Terr.
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Great
Britain (UK)
Greece
Greenland
Grenada
Guadeloupe
(Fr.)
Guam (US)
Guatemala
Guinea
Guinea
Bissau
Guyana
Guyana
(Fr.)
Haiti
Heard
& McDonald Isl.
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazachstan
Kenya
Kirgistan
Kiribati
Korea
(North)
Korea
(South)
Kuwait
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall
Islands
Martinique
(Fr.)
Mauritania
Mauritius
Mexico
Micronesia
Moldavia
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherland
Antilles
Netherlands
Neutral
Zone
New
Caledonia (Fr.)
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk
Island
Northern
Mariana Isl.
Norway
Oman
Pakistan
Palau
Panama
Papua New
Paraguay
Peru
Philippines
Pitcairn
Poland
Polynesia
(Fr.)
Portugal
Puerto
Rico (US)
Qatar
Reunion
(Fr.)
Romania
Russian
Federation
Rwanda
Saint Lucia
Samoa
San Marino
Saudi
Arabia
Senegal
Seychelles
Sierra
Leone
Singapore
Slovak
Republic
Slovenia
Solomon
Islands
Somalia
South
Africa
Soviet
Union
Spain
Sri Lanka
St. Helena
St.
Pierre & Miquelon
St.
Tome and Principe
St.Kitts
Nevis Anguilla
St.Vincent
& Grenadines
Sudan
Suriname
Svalbard
& Jan Mayen Is
Swaziland
Sweden
Switzerland
Syria
Tadjikistan
Taiwan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad
& Tobago
Tunisia
Turkey
Turkmenistan
Turks
& Caicos Islands
Tuvalu
Uganda
Ukraine
United
Arab Emirates
United
Kingdom
Uruguay
US
Minor outlying Isl.
Uzbekistan
Vanuatu
Vatican
City State
Venezuela
Vietnam
Virgin
Islands (British)
Virgin
Islands (US)
Wallis
& Futuna Islands
Western
Sahara
Yemen
Yugoslavia
Zaire
Zambia
Zimbabwe
Phone
Email
Address
What
method would you prefer us to contact you?
phone
e-mail
Best
time to contact you?